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Leveraging Data Analytics to Complement Value-Based
Approach
Session 97, February 13, 2019
Nathan Riggle, Director of Analytics, Mercy ACO
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An employee of Mercy ACO
Mercy ACO is a client of Innovaccer
Innovaccer has sole ownership and rights to their data activation platform
Conflict of Interest
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Mercy ACO background
Strategic priorities
Current data systems in the industry today
Mercy ACO’s Strategy
Data Activation
Analytics
Patient engagement
Mercy ACO’s Performance
Closing thoughts
Q&A
Agenda
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Develop a complete patient picture by leveraging multiple data sources
Recognize the need for data-driven approaches to improve workflows,
close gaps in care, increase communication, reduce SNF and ED
utilization, and promote community engagement
Explain the key elements for creating the necessary infrastructure to
redefine the process of healthcare delivery
Develop growth strategies with the use of data analytics to complement
a value-based approach
Learning Objectives
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Mercy ACO Background
Mercy ACO as our foundation
Mercy ACO is a subsidiary of MHN
6 (regional) ACO Chapters
67 of 99 Iowa Counties
2012 Track 1 MSSP “Mercy ACO”
2017 moved to ‘downside risk’
(1) Track 3 MSSP (up/downside risk)
(1) Track 1+ MSSP (up/downside risk)
(2) Track 1 MSSPs (Rural/Urban)
(5) Commercial Shared Savings Programs
Partnered On/Off Exchange Product
Independent & Specialty Groups
195+ Participant Organizations
3,500+ Providers
Government & Commercial Contracts
310,000+ Covered Lives
20+ Value Based Contracts
3-day SNF Waiver
North
Iowa
Central
Iowa
Siouxland
Dubuque
Clinton
Waterloo
Medicare Shared Savings Program
Commercial Shared Savings
Direct to Employer
Medicaid
Medicare Advantage
Partnered On/Off Exchange Product
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Mercy ACO’s data journey
1995 Excel spreadsheet to track Diabetes and HTN
Tracking a population greatly improved clinical outcomes
1998 - home grown SQL registry
Lab data dump for HgA1c and LDL
2003 2012 Free registries from QIO
Manual Data Entry for HgA1c, LDL, BP, UACR
Health Coaches introduced in 2004
2012 - MedVentive / McKesson
Automated data entry claims and EMR
2015 - Innovaccer
Automated data entry claims, EMR, PPMS, ADT
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Mercy ACO Strategic Priorities
Manage risk for population
Manage the total cost of care
Lower network leakage
Data-driven care management
Identify growth opportunities
Create value for population
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Often “care” looks like this…
Bad Delivery Systems
Duplication
of Effort
Gaps in
Communication/Care
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Where data systems look like this...
Disparate data systems Analysis-paralysisLack of interoperability
EH
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Mercy ACO’s data needs
Data activation - aggregation and normalization
Metrics & Performance measurement
MSSP metric reports
Customized metrics
Provider performance reports
GPRO reporting
Care management workflow & documentation
Work queues & Care Models
Gaps in care
Productivity monitoring
Community Resources
Security, Privacy, Data segmentation, and ACO Interoperability
Analytics
Episodes
Network leakage
Risk scoring Clinical Documentation Improvement (CDI)
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Mercy ACO’s data infrastructure
Our data infrastructure is built from over 100 Clinical
System data feeds across Iowa, including 15+
different EMR brands.
This level of data integration provides a more
complete Patient Profile, for Care Management and
improved Patient Engagement.
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Innovations in care delivery are not
possible without activating the data
Population Health
Risk Management
Care Coordination
Quality & Performance
Reporting
Predictive Analytics
Electronic Health Records
Payer Claims
Billing Systems
Other
Clinical Systems (labs)
Public Sources (IHIN)
Disease Registry
Internal Sources
External Sources
Care
Management
Documentation
Platform
Risk Analytics
[ Data Activation Platform]
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Analytics for High-risk Segmentation
Anyone with a hospital admission
For MSSP 17.6% are readmitted in 30 days (nationwide)
Mercy ACO readmission rate is 14.3%
3 or more ED visit in the previous 6 months
Anyone with Dx of HF or COPD
Anyone with 2 or more chronic diseases
High cost or high risk score (top 1%)
Not a good population to improve health outcomes
40% are dead when Identified by claims
Other High Cost / High Risk strategies
Rising risk
Persistent high needs
High risk list reviewed by PCP for best opportunities
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Analytics to keep track of critical metrics
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Mercy ACO’s strategies and protocols for
high-risk patients
Initiate with face-to-face visit
Medical conditions and Medications
reviewed with teach back
Red flags warning symptoms and what to do
Self Management Support and Goal setting
Motivational interviewing in the 5As Framework
Agree, Assess, Advise, Assist, Arrange
Tobacco Screening and Cessation
Depression Screening
Advance Directives / Palliative Care
Follow weekly for 6 weeks
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High-risk protocols: Populate automatically
when the bundle is created
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Engaging patients for value-based
outcomes
Event Based
Admission Discharge - Transfers
Emergency Department Utilization
Improved Communication
Continuum-of-Care virtual “Hand-
offs”
“Social Media” (like) Patient Care
Timeline
Closing Gaps in Care
Quality Metrics “Gaps-In-Care”
Increasing Annual Wellness Visits
Community Engagement
Community Resources
Community Care Collations (C.C.C.)
Community Health Workers
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Event Driven-Patient Engagement
Admission-Discharge-Transfer (ADTs)
35+ Hospital ADT Connections + State Health Information Exchange
“Strategy” triggers populate Health Coach daily schedules (work queues)
Standardized process flows from Admission Discharge – back to “Medical Home”
Result: 7.14% in 30d Readmit Rate (14.3%) - 2017
“Strategies” Prioritization
&
Care Manager Alignment
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Event Driven-Patient Engagement
Emergency Department Utilization
Monthly Claims + “Real-Time” Electronic Health Record connection analytics
“Strategy” triggers populate Health Coach daily schedules (work queues)
Standardized process flow for “High Risk” patients – back to “Medical Home”
Result: 6.65% ED Utilization/1k (632/k) - 2017
Rural Health Coach Stories
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Gaps in Care- Patient Engagement
Quality Metrics Closing Gaps-In-Care”
Single Patient profile based on numerous data sources
Proactive/Reactive identification to close gaps-in-care
Outreach/engagement via Health Coach Assistant/Clinic Staff
Multiple Chronic Conditions
Result: 14.26% Primary Care Services/1k (8,684/k) - 2017
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Gaps in Care- Patient Engagement
Annual Wellness Exams
Provider engagement and incentive alignment
Monthly Claims monitoring Chapter level to Provider level performance
reports
Outreach/engagement via Health Coach Assistant/Clinic Staff
Qualified members based on claims data
Result: 9.15% Annual Wellness Rate (31%) - 2017
*With some sites 70%+ Completion Rates*
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Communication- Patient Engagement
Continuum of Care “Virtual Handoffs”
Standardized workflows across the “continuum-of-care”
Health Coach + Navigator + Acute Care Manager + Post Acute Health Coach
Provides a mechanism that is patient centered
Ensuring “warm handoffs”, “gaps-in-care” are closed and, aligns as well as
adjusts to our internal workflows versus the other way around.
Result: 95.7 new engagements/Month/Health Coach - 2017
“Social Media” (like) Patient Care Timeline
Increased visibility of Care team interactions
Patient Centered Approach
Other linked Care Team members
Personal information outside of demographics alone
Patient Goals
Linked (Community) Resources
Result: 95.7 new engagements/Month/Health Coach - 2017
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Community - Patient Engagement
Community Resources
Sticky notes, rolodexes, Outlook contacts and, scraps of paper to an
electronic directory
Non-clinical, but relevant resources to addressing social factors
(transportation, meals, etc).
Result: “Virtual rolodex” of hundreds of geo-tagged community
resources and an ability to track linked community resources at the
patient level
Expanding our platform & ACO processes to Community Partners
Rural Network Participants (Nearly Complete)
Community Health Workers (In Process)
Partnered SNF Facilities (In Process) and
others (ongoing)
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Mercy ACO VBC Performance
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Key outcomes
7.14% reduction in 30d Readmit Rate (14.3%) - 2017
6.65% reduction in ED Utilization/1k (632/k) - 2017
14.26% increase in Primary Care Services/1k (8,684/k) - 2017
9.15% increase in Annual Wellness Rate (31%) - 2017
~280% increase in cumulative total return - 2017
$100 million+ reduction in health care expense for Iowan’s (2012-17)
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Closing thoughts
Abundance of data and information = Analysis paralysis
Focus on the few measures and processes that will have the biggest impact
(Strategies)
For Mercy ACO; Annual Wellness Exams, ED Utilization, and ADTs
Connect with community partners/resources (they often eager to be
engaged)
Select a vendor, or develop your platform, that is flexible enough to mimic
your processes/workflows, again not the other way around
Looking ahead...
We’re excited for even more data to determine which of our
interventions have the biggest impact on Patient Engagement and improving
the health of our population.
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Questions?
Contact information
Nathan Riggle: <NRiggle@mercydesmoines.org>
Organization information
Mercy Accountable Care Organization
1449 128th St., Suite 110, Box 7
Clive, IA 50325